PLAYA MARINA WALK IN URGENT CARE CENTRE
TRAVEL HEALTH
You may receive one or more of the following vaccines. Side effects are usually very mild and last 1-2 days.
Getting plenty of sleep on the evening of the injection will help avoid the systemic symptoms. Acetaminophen
(Tylenol) will be helpful for most symptoms. Please be aware of the following specific possibilities:
CHOLERA:
• redness, swelling, tenderness at the injection site
• headache, tiredness, mild increase in temperature
GAMMA GLOBULIN:
• pain and tenderness at the injection site
• hives with itching
HEPATITS A:
• pain, redness and tenderness at site of injection
• headache, malaise, low grade fever, fatigue, nausea
MENINGOCOCCAL:
• redness, swelling, tenderness at the injection site
• headache, tiredness, chills, mild increase in
temperature
TETANUS:
• redness, swelling, tenderness at the injection site
TYHOID INJECTABLE:
• redness, swelling, tenderness at the injection site
• headache, tiredness, muscle aches and mild fever
ORAL:
• Be sure to refrigerate your medication!
• upset stomach, headache, tiredness, muscle aches
YELLOW FEVER:
• fever or localized tenderness occurring 7-14 days
after injection
POLIO VIRUS:
• redness, swelling at the injection site
• mild fever
If you experience any side effects not listed above or have any questions about the development of any side
effects related to the vaccines, please don’t hesitate to contact your physician.
continued...
4560 Admiralty Way Suite 100 Marina Del Rey, CA 90292 (310) 827-3700
(310) 578-5379 Fax
Travel Questionnaire
Name: ________________________
Date: _________________________
Welcome to Playa Marina Walk In Urgent Care Center. Our goal is to keep you healthy for you entire trip. We
have put together this questionnaire to help identify any special medical requirements or immunizations that
you might need for healthy travel.
Please list the countries on you itinerary in the order you plan to visit them along with how long you will be in
each country:
Date of departure: ________________
Country
Length of stay
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
During childhood did you complete the immunizations for:
Diptheria
_____Yes
_____No
Pertussis
_____Yes
_____No
Tetanus
_____Yes
_____No
Measles
_____Yes
_____No
Mumps
_____Yes
_____No
Rubella
_____Yes
_____No
Polio
_____Yes
_____No
Was your last tetanus shot within the past ten years?
Are you severely allergic to eggs?
Are you allergic to sulfa?
Are you allergic to aspirin?
Are you Pregnant?
Will you be traveling to high altitudes?
_____No
_____No
_____No
_____No
_____No
_____No
_____Yes
_____Yes
_____Yes
_____Yes
_____Yes
_____Yes
Will you be traveling to rural or remote areas not on
the usual tourist routes?
_____No
_____Yes
Are you taking any prescription medications?
_____No
_____Yes
continued...
4560 Admiralty Way Suite 100 Marina Del Rey, CA 90292 (310) 827-3700
(310) 578-5379 Fax
Travel Questionnaire ...continued
Are you aware of any special medical conditions that might affect your
health on this trip?
_____No
_____Yes
If yes, please list:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Are you aware of any special medical or immunization requirements
for your trip?
_____No
_____Yes
If yes, please list:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Have you ever been vaccinated against the following diseases?
If yes, please list the approximate date it was given.
Cholera
Gamma Globulin
Hepatitis A
Hepatitis B
Meningitis
Plague
Typhoid
Yellow Fever
Polio
_____Yes
_____Yes
_____Yes
_____Yes
_____Yes
_____Yes
_____Yes
_____Yes
_____Yes
_____No
_____No
_____No
_____No
_____No
_____No
_____No
_____No
_____No
Date
Date
Date
Date
Date
Date
Date
Date
Date
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
(6mo)
(10 yr)
(5 yr)
(3 yr)
(1yr)
(3yr)
(10yr)
4560 Admiralty Way Suite 100 Marina Del Rey, CA 90292 (310) 827-3700
(310) 578-5379 Fax